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Application Form

Please see Join Us for information about membership benefits, categories and criteria.

Please indicate which category of membership you are applying for:

Membership Type:*

Name:*

Address:*

Note: this will not be included in the public register on the website

Work Location:*

(e.g. town/city/suburb) Note: this will be included in the public register on the website.

Phone Number:*

Mobile Number:

Email Address:*

Website Address:

Ethnicity:

Optional. Please indicate if you would like this included in the public register on the website

Which professional associations do you belong to:

(Note: members must belong to another professional association that has a code of ethics)

NZ Associations Of Counsellor:

NZ Association of Psychotherapists:

NZ Psychological Society:

Other professional association/s: (please specify)

Do you have indemnity insurance? (Note: NZ Institute of Psychosynthesis trainee members are exempt from this requirement as they are covered while in training)

Which Psychosynthesis qualifications do you have?

NZ Diploma in Psychosynthesis Counselling:

NZ Diploma in Psychosynthesis Pyschotherapy:

Other qualification in Psychosynthesis Counselling and/or Psychotherapy (please specify)

Please list any relevant non-Psychosynthesis qualifications:

PBANZ Registered:

Offers Supervision:

ACC Registered:

Family Court Registered:

Areas of specialisation:

Children/Adolescents:

Couples:

Alcohol/Drug Abuse

Eating Disorders:

Other (please specify)

In submitting this form, I confirm that the above information is accurate.

Yes I Agree: